Nurses take evidence-based research improvements to Africa
Sometimes the lessons learned during the journey toward ANCC Magnet Recognition Program® (MRP) designation are truly worth sharing—even half a world away.
Barbara Buchko, MS, RN, clinical nurse specialist in Women and Children Services at WellSpan Health’s York Hospital, and Linda C. Pugh, PhD, RNC, FAAN, director of evidence-based practice (EBP)/nursing research at York Hospital, were asked recently to take their knowledge of EBP on the road—or more accurately, up in the air. The nurse educators were invited to a hospital in Nairobi, Kenya to help improve its EBP program. The two recently visited the facility—Aga Khan University Hospital, a modern 250-bed facility—at the request of Zeenat Sulaiman, MScN, RN, the hospital’s chief nurse.
“We at York had been working to build an infrastructure to support evidence-based practice and research,” says Buchko, who studies at Johns Hopkins University with Sulaiman, where the connection was first established. She had presented on the topic at the 2009 ANCC National Magnet Conference® as well.
“[Sulaiman] invited me to come to her hospital to speak [with Pugh],” she says.
There was a lot to do, and not a lot of time to do it. Pugh and Buchko were in the air just weeks after the decision was made. The plan was to replicate existing workshops they had done at their home facility.
“We landed Wednesday and hit the floor the next day,” says Pugh.
The pair started off with an all-day leadership and faculty conference on day one of the visit, discussing the characteristics of the MRP designation and how to integrate an EBP program into a curriculum.
“It was really an overview for nurse leaders and the faculty at their school of nursing,” says Pugh.
The next five days, however, were much more hands-on—they delved into workshops with bedside nurses, teaching them how to identify sources and put into practice successful processes that had been implemented at York Hospital.
“We have a culture of inquiry,” says Pugh. “We want our nurses to feel like they can question their practice and ask, ‘How can we deliver best practices for all patients?’ ”
Pugh and Buchko met with the leaders of Aga Khan’s service lines and identified two areas to focus on to implement key EBP processes.
“We knew once we met with the staff nurses we would work with the med-surg unit and maternal health,” says Buchko.
The goal of the visit and the workshops was to try to present a process for how the hospital could perform EBP and use that research to support best practices in a systematic way. Aga Khan could not have asked for more experience—Pugh is one of the authors for the Johns Hopkins EBP process, the model used at York Hospital.
“We actually presented that model and demonstrated how they can use the process in terms of developing practice recommendations,” says Pugh.
EBP really is the core of a culture of inquiry, Buchko and Pugh explain. Make sure nurses know it is okay to question a practice that seems ineffective and suggest methods for how to perform better.
“The whole focus for all of us is to find efficient, effective ways to make clinical and administrative decisions,” says Pugh. “How do you make those decisions? How did you use research to recommend practices that are the most efficient in terms of patient outcomes?”
The model York uses, and the model that Buchko and Pugh used in their workshops, were based on the Hopkins model.
In EBP, the process is to identify the practice question, find evidence, and appraise that evidence, which can then be translated into practice.
“Translation is the toughest part,” says Pugh. “It’s hard to sustain change.”
One of the advantages to the Hopkins model is that it has a unique focus on tools to help nurses appraise their evidence, explains Buchko.
“It leads you through and asks you questions,” she says.
For bedside nurses, Pugh says, reading through cold statistics can be challenging. “This helps them choose evidence—some research isn’t of the highest quality—how do you identify the good and the bad?” she says. “You need to find the rationale for practice recommendations.”
“After we met with the two groups, we went through three full days of how to create a question to be answered and how to review appropriate literature,” says Buchko. “Those three days were meant to help them jump-start two projects, one for each service line.”
The nurses chose the question they wanted answered and headed for the library.
“It’s amazing what the librarians had access to,” says Pugh. “They have access to a worldwide database for developing countries free of charge through the World Health Organization.”
“It’s even more extensive than our access back home!” adds Buchko.
The workshops pushed the nurses to develop teamwork in order to help keep the project on track. Team leaders were chosen for each project, one nurse leader and one bedside nurse with recommendations from the chief nursing officer.
The teams then dug into their research, flagging articles, reading evidence, and formulating a timeline for implementation that would continue moving forward even after the workshops were over.
“In the time we had, there wasn’t enough time to review all the literature,” says Buchko. But she and Pugh have stayed in contact with Sulaiman, and just a month out from the visit, the two units are translating the evidence into practice.
The med-surg unit targeted pressure ulcers for its topic, looking into turning and use of mattresses and their impact on ulcers. The maternity unit looked into IV cannula change frequency, exploring whether any change in number of bloodstream infections occurred if the IV cannula was changed every 72 hours versus more than 72 hours.
But what did the teachers take away as lessons of their own from their students? “We confirmed that nurses are smart, no matter where you are,” says Buchko.
The students already had a background in EBP, and their level of awareness impressed both of the guest instructors.
Aga Khan is undergoing a transformation to improve quality beyond EBP training. The hospital recently made a decision to require all nurses to hold a bachelor’s degree by 2014—and Buchko and Pugh noted that many of their students would rush out from their workshops to attend classes toward that requirement.
The hospital is working on becoming Joint Commission International–accredited and plans to seek MRP status in the future.
“They felt that if they were doing one, they should also be looking into the other,” says Pugh. “They have the infrastructure in place for the components the [MRP program] is looking for.”
York Hospital was incredibly supportive of the opportunity to send two of its nurse leaders overseas.
“Our CNO, Valerie Hardy-Sprenkle, MPH, RN, NEA-BC, FACHE, was very supportive. When the discussion first came up, we were able to see that Aga Khan had the pieces in place for [designation] and we were told to move forward [with plans to visit],” says Pugh.
Buchko says she took away from the experience the importance of stressing independence in her students.
“I’m a clinical specialist as well as EBP codirector,” she says. “In my specialist role, I lead a lot of EBP projects, but I’m always there [physically]. When we were in Nairobi, I knew we had to leave and they had to keep going. The coleaders concept is something we will look into here at home. Currently our EBP forums are led by staff nurses, where nurses look at EBP topics systemwide, read articles, and make recommendations.”
If hospitals combine nurse leaders from service lines with bedside nurses, it may be possible to overcome some key challenges, particularly in terms of implementation. Having a clinical specialist or nurse manager teamed with a bedside nurse will help play to both parties’ strengths—the clinical specialist or nurse manager knows who the stakeholders are, and the nurse knows the process in the field.
Buchko and Pugh worked with close to 100 students at Aga Khan, split between leadership and bedside nurses.
The facility’s notion of patient care was the most outstanding take-home from the trip, says Pugh.
“When we were in Nairobi we were so impressed with the people we met every day,” she says. “Their customer relations were fabulous, and they had a sense of bright nurses and a belief that the patient comes first.”